Fluid overload in chronic kidney disease

Investigations

• BNP/NT-proBNP; creatinine, BUN, eGFR; serum and urine sodium, potassium, chloride; serum osmolality; haemoglobin/haematocrit; albumin and total protein.

Non-pharmacological management

• Salt below 90 mmol/day (about 5–6 g, one teaspoon); education on fluid and salt restriction and daily weight; avoid NSAIDs and fluid-retaining drugs; adjust doses to kidney function.

Pharmacological management

• First line: A: furosemide (PO) 20–40 mg once or twice daily, titrated up to 200 mg/day, OR S: torsemide (PO) 10–20 mg once daily, up to 200 mg/day.

• Add if diuresis is inadequate: D: hydrochlorothiazide 25–50 mg every 12 hours, OR S: metolazone 2.5–5 mg once daily 30 minutes before the loop diuretic (watch for low potassium and sodium).

• Monitor BP, electrolytes, kidney function and volume status.

Refractory fluid overload

• A: Furosemide IV 20–40 mg every 6–8 hours (up to 600–1500 mg/day in severe cases); maximum single bolus 160–200 mg; doses above 80 mg as slow infusion at no more than 4 mg/minute.

• OR S: torsemide IV 10–20 mg daily, titrated to 100–200 mg/day.

• With hypoalbuminaemia: S: albumin 20% or 25% 0.5–1 g/kg IV (maximum 2 g/kg/day; children over 30 minutes–2 hours), repeated every 24–48 hours, given with furosemide 1–2 mg/kg IV; avoid in uncontrolled hypertension, heart failure or pulmonary oedema.

• Refer to a nephrologist if refractory, or with resistant hypertension, rapid decline, severe albuminuria, electrolyte disturbance, AKI on CKD or need for dialysis; refer early once eGFR is below 30.